Will noise win again?

February 16, 2009

“If nothing is right and nothing is wrong, then the only thing that matters is who yells the loudest.”– unknown


In the absence of principle man will pursue power with all the energy in his possession.  I read the above quote somewhere when someone was talking about what they thought was wrong with America.  What he was trying to say was in the absence of shared principles and ideas about truth, that there was nothing to talk about.  All communication requires a shared context and without that we can’t even disagree, because even disagreement implies a common ground to disagree over.  As a description of the current political scene I think he is absolutely right.  All is noise.

I remember during Obama’s campaign I used to sit and turn the TV back and forth between CSNBC and FOX.  What absolutely amazed me was that these 2 “news” organizations would describe an event and if you didn’t know better you would say that it was 2 different events.  It seemed to be 2 different worlds with each claiming to be the “only real news.”

What I liked most about Obama is that he seemed to promise that it was possible for principle to triumph over power.  He seemed to give promise that the loudest noise didn’t have to win again.  He seemed to say that politics didn’t have to be the art of calling your opponent the worst name that you could get the most people to believe.  I still like that.

I listened to Rush Limbaugh talk about how he hopes the president of the United States would fail.  I thought about how many people I know are going through really hard times and what that failure would mean for all of us and I knew what Rush Limbaugh thinks of me.  I knew he was noise and his only weapon was to render us all helpless in the storms of his noise.

Watching it all I am really concerned.  I am by no stretch of the imagination a political wizard.  What I don’t know would fill many large boats.  But listening to the start of the Obama time I can’t help feeling like so many people would be content if it was all a battle to see who could yell the loudest.

The truth is that some things are right and some things are wrong.  One of my favorite movies is one called the “Marathon Man” with Dustin Hoffman and Lawrence Olivier.  One of the things that Olivier’s character keeps asking Hoffman’s is, “Is it safe….Is it safe….Is it safe….”  If you have the misfortune to be sick and dependent on our health care system the answer for too many people is simple, “It is not safe.”  It sure seems like it should be.

And I was sick

February 6, 2009

For the very first time last night I watched Michael Moore’s “Sicko.”  And I was sick.

For some reason I had always avoided it.  I am not sure why.  When it started I didn’t expect much, but decided to watch anyway.  Even allowing for his excesses and showboating at times, what I saw last night was heart crushing.  We are killing each other.  Insurance companies do business by trying as hard as they can not to insure anything.  Ordinary people who have the misfortune to get sick find out that they have less protection than criminals.  In Tennessee if you have no insurance and are sick I sometimes wonder if you need to consider going to prison where you will get the care you need.

We pride ourselves on being the most advanced and civilized place in the world, but a bunch of other countries understand something we don’t.  Life is about we and not about me.  Certain things should be automatic.  Health care is one. We shouldn’t have to worry ourselves to death.

If you haven’t seen it see the movie.  See if you don’t get sick too.

The stereotype of mental illness and violence

February 3, 2009

Another blow has been struck against the stereotype of the “violent crazy person.”  This is a belief held by many people.  Just read any local paper after a violent crime.  In a dressed up way this belief is also the centerpiece to the argument of people like the Treatment Advocacy Center.  It is a centerpiece assumption that lays underneath the stigma that those with mental illness deal with every day of their life- the idea that somehow they are diminished people that less should be expected out of , that should expect less from us.

There is an article in the General Archives of Psychiatry by Dr Eric Elbogen of North Carolina.  The study followed 34,000 adults.  Its conclusions were clear.  Mental illness, unless it is paired with substance abuse, a previous history of violence and several other factors is not predictive of an individual’s likelihood of violent behavior. 

I think we have known this, but to hear it being reinforced on such a grand scale is great.  As someone else pointed out mental illness is probably a greater predictor of being the victim of violence, rather than the author of it.

Maybe the next time there is a horrendous crime and we try to solve it by saying “He must be crazy” someone will stop and say— maybe there is more to it than that.  Calling names explains little other than you believe it does.

Another voice on mental health

February 1, 2009

Many people I know refer to themselves as “survivors” of the mental health system. 

Their experience with hospitalization was often to be diminished as a person and relegated to the status of a “crazy” who will never do better.  For too many their experience was to be either emotionally or physically abused. 

They are in deep conflict about their medications.  On the one hand many realize that without them they are unlikely to function well.  But many medications have with them radical side effects which make their daily life more difficult and in some cases side effects that may effect their health adversely for their entire life.  Every day there seems to be a new story about lies or outright fraud perpetrated by major pharmaceutical companies. 

Outpatient services for many are not easy to find.  For those who find them the demands normally outstrip the resources and they find themselves caught in a program with long waiting periods which at times seems more to endure them than to welcome them.

There is a different voice on the subject though.  The Treatment Advocacy Center believes that consumers have too much voice now and that stricter measures need to be taken.  They believe for example that we should make much more use of psychiatric hospitals.  They think that there should be 50 beds for every 100,000 in population.  For Tennessee if I have done the math right that would mean about 3000 beds.  With the current budget crisis the state plans to have 692 beds and cut outpatient services while they are at it.

They do not believe people should have choices about treatment either.  They believe in “assisted outpatient programs.”  This means if you refuse to take meds or participate in treatment and it appears you will go further downhill without treatment, that you have trouble meeting basic needs, you are a danger to yourself, or a danger to others that you can be court ordered to take meds/treatment or be locked up until you do.

They believe that about 50% of people with serious mental illness have anosognosia which basically means they are not aware there is something wrong.  They say this is biologically based and part of the mental disorder and because of it we can not be too concerned about what they want to choose in regard to their treatment options.

There are a bunch of problems with all of this:

  • The TAC keeps a catalogue of all the violent acts they can find committed by “emotionally disturbed ” people and tries to say that lack of treatment is the cause.  This scare tactic conveys the idea that in some way the mentally ill are more dangerous and violent than “normal” people.  This is simply not true and greatly reinforces a stereotype which reinforces the stigma about mental illness.  Violence is not an emotional illness issue per se.  It is a people issue.  Meaness and cruelty are not psychiatric categories.  If anything they are moral categories.
  • The whole idea about anosognosia has tremendous holes in it.  First of all it assumes that not doing what your doctors say and not knowing you are sick is the same thing.  If you are bipolar and you have went 10 years being diagnosed incorrectly you are likely to grow a healthy skepticism about what any doctor says.  Maybe I don’t know the right people, but I have never met anyone with bipolar disorder that doesn’t know that something is very wrong.  Might they have personal moments of blindness about their problems.  Sure- but don’t all of us have that.  We all have the ability to rationalize and close our eyes to the most stupid and self destructive things in the world.  That is not confined to those with mental illness.  They say that this anosognosia is because of problems with the right hemisphere.  Where exactly is the evidence that bipolar disorder or any other disorder is a disease of the right hemisphere.  I think in the end doctors believe that anyone who doesn’t do what they say must be mentally ill.  It seems more a matter of the personal blindness of medical professionals than the blindness of mental health consumers.
  • Related to the above- The TAC prescription implies that treatment is a cut and dried, black and white affair.  It isn’t.  It varies widely from doctor to doctor.  They can’t even agree what is bipolar and what is not.  Medication is for sure not a cut and dried affair.  When you are being given a medicine that may cause diabetes, heart problems, obesity and many other life altering events how can you criticize anyone who is reluctant to take those meds– even if they do help. 
  • Their proposal would result in a radical increase in the number of people in psychiatric hospitals.  This goes against everything that has been discovered about the dangers of institutionalization.  There is very little evidence of the efficacy of hospitalization.  It further perpetrates the myth that the mentally ill cannot function in the real world and by doing that drastically increases the stigma of mental illness.  I think it is that stigma that makes people hesitant to seek treatment and thus the TAC would be making less likely the very thing they say they want.  
  • Because this system would rely so much on compulsion and force it would create a system that would be very easy to get into and very hard to get out of.  We already have a system like that.  It is called the correctional system.  Look how effective that is.
  • These suggestions are so far out of touch with the economic realities of the world as to be psychotic in themselves.  They if anything are likely to have a rebound effect.  The system they describe would be much larger than the present one.  Because their solutions are simply not realistic I wonder how much it would make people think the problems are also not nearly as bad as made out to be.  I think serious consideration of these proposals would take attention away from much more practical and realistic ideas and make it harder for anything to be done.

The mental health system is in crisis.  In that the TAC is exactly right.  It is true that sometimes people are dangerous and we all need protection from them.  However their ideas go far past that.  They make assumptions that are simply not true or based on dubious assumptions or studies.  They go much further making mental illness as being even more a source of stigma than it is now.  In that alone they pose a real danger to anyone who struggles with mental health issues.

What we can’t afford to not afford

January 27, 2009

I heard a state legislator ask his colleagues one time, “How long can we afford to delude ourselves?  We work so hard to control short-term costs because we can’t afford them, but in the process ignore long term costs that are destroying us.”

I think it is a little like trying to figure out how to safely swim in a river of alligators rather than trying to figure out how not to get in the river.  Eventually the gators will get you.  Our health care system can’t figure out how to get out of the river.

Just looking through the papers is like watching a disaster unfold.  We are worrying about asteroid dust, while the big meteors are headed directly towards us.  Just look at a few of the events:

  • Unemployment continues to rise.  Most states report a 5-10% rise in Medicaid.  They can’t pay for what they have now.
  • Those who have jobs are finding health costs spiral through the roof.  They are eating up more and more of salaries.
  • More people are deciding which medication to take or if they can take medication than ever before.
  • Some doctors are reporting increases in sickness, because people can no longer afford the food or other things they need to live a health life style.
  • As stress increases the need for mental health services are rising.
  • The budget for mental health services is decreasing rapidly.
  • No one knows which business is going under next.
  • Without mental health services effectively provided the jails, the homeless, and suicides are sure to rise.
  • The papers are littered with stories of big pharmaceutical companies employing deceptive practices to people that don’t work near as well as advertized and which in some cases leads to disastrous side effects.
  • The medical system is seen by too many , not as a source of opportunity to make their life better and longer, but as a source of deprivation only their to line their own pockets at the expense of ordinary people.

And then recently I saw another story.  A group in California had done a study that showed that the movement to a single payer system would add over 2 million jobs, as well as having  considerable other positive economic impacts.  And that doesn’t include what it would do for the general health.

There is something we need to understand and make sure our folks in government both understand and act on.  Health care reform is not what happens when the economy gets back on board and we can “afford it.”  Health care reform is a major part of getting the system back on board.

We don’t have to swim with the gators.  There are other rivers.

The news on mental health– and it ain’t good

January 24, 2009

The news is in on coming attractions for the Tennessee Mental Health system.  And it ain’t good!

I attended the Tennessee Coalition for mental health and substance abuse services regional forum today.  Let me summarize what I learned.

  1. Right now the state budget in Tennessee is looking at budget reductions of $800 million to $1 billion.
  2. The state department of mental health is being told to eliminate 15-20% of its budget. 
  3. The original plan for MH before the budget shortfall was to reduce beds from942 to 795 by 2010.  The savings from this were to be reinvested in community based programs to more adequately meet the needs of consumers and keep them out of institutions.
  4. The department has been asked for deeper cuts.  They are to cut beds to 671.  None of the savings is to be re-invested in community programs.  The net effect is to have a department that is keeping pace barely, if at all, further  and further behind.
  5. Even with these cuts the department will still be responsible for providing care for two uninsured groups formally covered by TennCare.  These are the “State only” and “Judicial” categories.    The “state only” category are low income adults presumed to be elgible for TennCare.  Through this category they can be served while they are applying.  TennCare spent $43 million on them in 2008.  The judicial category is those committed in judicial procedures.  The department is planning on serving both groups for $20 million. 
  6. When the Daniels class suit is finally settled 150,000 people will lose their TennCare.  Of those 15-20 thousand have primary mental health diagnosis.  This will be 20,000 people additional put into the the uncovered pool.
  7. As the economy worsens and more people lose their jobs the amount of  uninsured can only rise.
  8. If  the department cannot cover the uncovered there are only two options.  MH centers will have to bite the bullet and cover them.  They will have to go without coverage. 
  9. The net effect of this is far less money to pay for services and far more people needing them.
  10. The impacts of this are massive and will be felt on every level of society from increased suicide, increased jail population, and massive economic costs.
  11. There is no money to keep Crisis Reponse Teams going past this fiscal year.  $4.3 million is needed.
  12. Crisis Stabilization Units have recieved money finally to start up.  They anticipate their population will be as much as 40% uninsured.  $4.4 million  is needed for the next fiscal year.  It doesn’t exist.
  13. There is also under consideration a new provision to make the commitment to a state hospital “dependent on bed availibility.”  That means that a suicidal person may find out he has no place to go “if the inn is full.”

The net effect of this is a coming catastrophe.  These does not even really discuss the decrease in TennCare reimbursement rates for mental health services.  Many providers are trying to decide rather or not to even sign contracts for the next fiscal year.

1 in 4 citizens of Tennessee have diagnosable mental health conditions.  1 in 4 citizens of Tennessee are facing a challenge to maintain their sanity and ability to cope effectively with the world because the state of Tennessee will not be able to provide the services they need to have their chance for a happy and fulfilling life.

If you are concerned it is time for you to act.  Support the allocation of federal stimulus to TennCare.  Tell your elected officials on every level your concerns.  Our hope is in the actions all of us take.  Without action  the path ahead is clear.  And it isn’t going to be pretty.

Thanks for reading.  I hope I will hear further from some of you.

“Our Daily Meds”

January 23, 2009

Melody Petterson has written an absolutely essential book, “Our Daily Meds.”  It is subtitled, “How the pharmaceutical companies transformed themselves into slick marketing machines and hooked the nation on prescription drug.”

This book makes you want to scream, holler, cry and then scream some more.  If you want to have a literate opinion about what is going on in American health care it is an essential book to read.

She makes a simple point.  The mission of the pharmaceuticals is not to discover medications.  It is to sell medicines.  She describes in great detail the machinery they have put into place to do this.  For example, in the first chapter she explained how they made going to the bathroom frequently a disease in order to sell Detrol.  Her description of ‘how diseases are created” out of the ordinary events of life is worth the price of the book itself.  After reading her descriptions it is hard to tell the difference in the way McDonald’s sell Big Macs and the pharmaceuticals sell medicine. 

Rising pharmacy costs are a huge part of the health care crisis in this country.  As I mentioned in the previous post they have redefined  what mental health care is.  They are the iceberg on which any plan to reform the health care system is likely to wreck on.

My next post will also be about this book and focus on what Peterson has to say about pharmaceuticals and mental health treatment.

READ THIS BOOK.  It will be well worth it.

The paradox of mental health funding

January 20, 2009

The previous post talks about the crisis in mental health services coming.  States are in financial straits and funding for mental health services promise to drop.  Funding was already too low and now it promises to go past low.  The prospects for tragedy and crisis are real.  Look again at “The Coming Crisis” for a discussion of that.

I want to talk about another aspect of the funding crisis that is rarely looked at or talked about, but one I think that is central to the problem.

This is the paradox.  Mental health treatment is becoming more and more medicalized.  Pharmaceutical companies preach the glory of “got a pain-get a pill.”  Off label uses are growing for medications.  In 2007 zyprexa, risperidol, and seroquel were 3 of the top 10 medications in sales IN THE WORLD with sales of 14.5 billion dollars.  Think about that for a moment.  With the prevalence of cancer, heart problems, diabetes etc. in the world 3 atypical antipsychotics come in at the top of the sales list.  Medications are being touted as the cure to all psychiatric conditions for all ages.  Article after article talks about the risk of adverse affects particularly for the young and the very old.  Yet the rate of growth continues.

CriticalthinkRX.com is a site that funded by the state attorney general’s office in Florida that talks about widespread use of medication for kids as young as 5 years old.  In 2004 more money was spent on antipsychotics, than on antibiotics and asthma medication combined.  The site talks about the way that medication costs continue to literally eat Medicaid budgets.  Its focus is on the medication of kids in Florida, but I urge you to take a look at it and the information it provides.

Reports are easily and frequently availible that talk about things like the insufficient research and outright fraud that much of this drug use is based upon.  The side-effects of many of these meds are extremely dangerous and yet prescriptions continue to balloon.  Risperodal and other antipsychotics have been indicated to cause a risk for cardiac problems.  The also cause serious metabolic problems like diabetes.  Can they be helpful and even necessary.  Of course.  But that doesn’t mean in the rush to treatment that eyes should be shut.

The role of psychiatrists have been totally redefined in the medication revolution.  They are now almost solely pill people who normally see large amounts of patients in 15 minute blocks.  Therapy is considered a waste of their time and insurance companies discourage it.

In Tennessee the biggest pressure on the TennCare budget has been the rise in medication costs.  It is literally eating money alive that might be spent somewhere else. 

The paradox is this.  As expenditures increase to provide the medication treatment that we are told is indispensable the ability to pay for other services is shrinking and shrinking fast.  As things are reduced to purely medical issues our willingness and ability to deal with things as issues in effective living  is decreasing.

The pharmaceuticals have shown they can not be trusted.  The pressure now is to come up with new diseases and disorders that we can then prescribe for .  Difficulties in life are now medical problems.  Whatever happened to the idea that an integral part of life was its difficulties?  More medications are being developed faster with less research to “cure” more things than ever before.

Until we start treating mental health treatment as something that really matters– as something more than popping a pill– it is unlikely that we will ever find enough money to provide it to the people who need it.

The Coming Crisis

January 16, 2009

I live in Tennessee and some of what I am about to say may only be true in Tennessee, but I suspect most states are looking at similiar prospects.  A mental health system filled to the busting point and already in crisis faces the prospect of a even greater crushing crisis in the months ahead.

The state insurance in Tennessee is called Tenncare and sometime in the next few months (no one is exactly sure of a starting date) about 150, 000 people will be taken off Tenncare.  A federal judge has given the okay for this to happen and it is just a matter of when the state gets the machinery in place to make this happen.  The state economy is in deep trouble.  The state will collect no where close to the money they say they need to run the state and the pressure to make these cuts is extreme.

The people cut will be among the sickest of the sick.  About 20,000 of these people have primary mental health diagnosis.  These people will be people who can no longer secure medication and no longer pay for the counseling and therapy they need to function effectively.

The mental health centers in Tennessee are already past capacity.  The waiting period for an assessment in my county is 6-12 weeks depending on which mental health center you go to and what your circumstances are.  It can be much longer than that to be seen by a psychiatrist.

Reimbursement rates are being cut back by the state and many providers are trying to decide whether or not they can even afford to sign contracts to serve clients with state insurance.  Providers that provide inpatient beds in particular are likely it seems now not to sign contracts.

The jails are our largest mental health facilities.  It is so bad that the judge in Davidson County (Nashville) of the mental health court has started his own foundation to make sure that the people who come throught that court can get needed medication.  Jails are filled to the busting and are only going to get more full as times get harder.  People who get sent to jail who have mental health conditions are much more likely to be returned to jail again and again that those without mental health conditions.

Insurance is tied to employment and as the unemployment rate in Tennessee continues to go up the prospects of more people with mental health needs with no access to treatment resources continue to grow.

The state can say that they will not pay or help people to access treatment resources, but that only solves their problem short term.  The people do not go away.  They will not remain quiet.  Someone will have to pay the costs.  Even if the costs are rising jail populations, rising homelessness, increased suicide, increased substance abuse someone still pays.

Treatment providers who are trying to figure out how they are going to survive are about to be flooded with people who simply cannot pay for the services they need.  The prospects for tragedy are real and heartbreaking.

My wife and I run a support group for people with bipolar disorder and depression and many of the people we know are scared to death.  People are afraid of what is about to happen.  We get questions every day from people who want to know what to do when they can’t get meds, or who are afraid of how they are going to take care of their children when they can’t even function themselves because they can’t get the meds or help they need.  Most of the professionals in the mental health field I know are afraid.  Everywhere I hear, “The worst is yet to come.”

There are many things that people can do:

  • A large part of the solution must occur on the national level.  Make your voices heard.  If there are advocacy groups in your state that you can ally with it is important you do so.  In Tennessee one group is called the Tennessee Health Care Campaign.  There are I am sure similiar organizations in most states.  Maximize the impact your voice has and get involved with others.
  • Start educating and talking to state and local officials now.  Make sure they understand the crisis and in particular make sure that they understand that this will affect everyone in some way.
  • Write to newspapers, talk to churches, talk to people. Spread the word.
  • Tell other people involved in advocacy what you are doing.  Many people in different states are facing similiar challenges and we can learn from each others experiences.  Tools like the internet with things like google groups or yahoo groups might be one way to do this.

I would be interested in hearing about the ideas that others have.  The  Titanic is on the seas and I hope it can be turned before we hit the icebergs.

Physicians for a national health program

January 10, 2009

Physicians for a national health care program (www.pnhp.org) is one of the most important organizations in the country in the field of health care reform.  Other organizations are bigger, but few have a more important role.  One of the unique things they do is try to talk to physicians still in medical school to make sure that they not only know about medicine, but about care.  They are about increasing vision and do a great job.

They are also a great source of a lot of information about the health care system.  I know they have strongly affected me and the way I look at things.  They are enthusiastic backers of a single payer system.  If you are not sure what that is or if you do know and think it is a bad idea you owe yourself a few minutes to hear their case.  It might just change the way you think.

It is as I said a national organization.  The head of the Tennessee chapter is Dr. Art Southerland from Memphis.  The chapter does accept membership from non-physicians and I recommend you contact him to learn more (www.pnhp.org) .

They can be a valuable resource in your advocacy efforts.  I hope you will make use of them.